Healthcare Provider Details

I. General information

NPI: 1114529690
Provider Name (Legal Business Name): ANAILSE MARTINEZ RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7811 MCPHERSON RD
LAREDO TX
78045-2802
US

IV. Provider business mailing address

646 S FLORES ST
SAN ANTONIO TX
78204-1219
US

V. Phone/Fax

Practice location:
  • Phone: 855-481-1149
  • Fax:
Mailing address:
  • Phone: 855-481-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86052926
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: